This topic may seem a little off the dysphagia path, but it’s not, trust me. I have actually thought a lot about NSOMES in my therapy as of late. Not only does NSOME, at least in my eyes, stand for Non-Speech Oral Motor Exercises, I also use the term for Non SWALLOWING Oral Motor Exercises. This was the March topic for the SLP Chat, which was a very interesting conversation. I also went to a session on NSOME’s at our state convention, which actually turned into an artic course using core vocabulary which upset me immensely since I was hoping to learn a little more about NSOME’s.
First, let’s start with these exercises. What are they? Non-speech (swallowing) imply that these are movements that are not concurrent with producing sounds or swallows. These are the typical stick out your tongue 10 times, move your tongue from corner to corner of your mouth. These are actions that we use to “strengthen” the speech/swallowing mechanism by having our patients move the articulators.
Now I’m switching to all swallowing-hey that’s what my blog is about. It’s my blog!! So, anyway, who hasn’t been to a facility and observed the SLP there. What do they usually do for swallowing exercises. Stick out your tongue, try to touch your nose with your tongue, move your tongue from corner to corner of your mouth, stick out your jaw…….all of these 10 times, 3 times a day. So, 30 times total. How many of these patients truly get better with only these exercises?? In my experience, very few.
Robbins, et al wrote a very good article about neural plasticity in swallowing. I actually reviewed that article in an earlier blog. One principle is that plasticity is experience specific, or that to make neural changes (i.e. to the swallowing mechanism) the experience has to be specific to the actual movement. So, to improve the swallowing mechanism, you have to practice swallowing. To make neural changes to the swallowing system, the patient has to SWALLOW! What a novel idea.
Dysphagia therapy is quickly moving to a very exercise-based therapy. No, not the typical stick out your tongue exercises. When you exercise the swallowing system, there are very few researched techniques, however they do exist. With all the changes in therapy and in insurance, healthcare, now is most definitely the time to move to evidence-based practice, if you haven’t already jumped on board. I have my list of exercises that I use that are swallowing-specific and have evidence to support them.
Tongue exercises using resistance, i.e. tongue depressor or IOPI. Robbins et al looked at the IOPI 10x/3xday against the tongue tip, blade and dorsum with improvement with swallowing. (Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L., & Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 53, 1483-1489.) Lazarus, et al looked at the IOPI vs. a tongue depressor and found that the tongue depressor exercises worked just as well as the IOPI exercises. (Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrica et Logopaedica, 55, 199-205.) So, I have my patients use a tongue depressor and push their tongue against it using protraction, elevation, depression and lateralization, 10x each, 5x/day, 5 days/week.
Mendelsohn Maneuver uses resistance with swallowing. You can continually add resistance if you have the capability to use sEMG with your patients, which unfortunately I do not have at this time. With the Mendelsohn, you not only have resistance, but the entire exercise involves the act of swallowing, therefore it is a relevant exercise to improve the swallow. (Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language, and Hearing Research, 51, S276-300.) (Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Parts I-V. JRRD, 46, 175-222.)
The Masako technique is a little bit questionable with therapy. Yes, it does involve a swallow, however, how often do you swallow with your tongue sticking out??? This exercise should be used with caution, and should never be the only exercise you use, but may be a good exercise paired with another exercise to improve tongue base retraction. So, possibly have the patient use the Masako and then the Mendelsohn?? (Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language, and Hearing Research, 51, S276-300.)
The Shaker exercise offers not only resistance using the head as weight, but repetition of the exercise. Logemann and Eastering both have research for the Shaker exercise available, however use caution with this exercise, particularly for cardiac patients. I have been to a conference where I learned the Neckline Slimmer (https://www.buynecklineslimmer.com/) using the highest resistance spring can do the same as the Shaker without the strain on the patient. However, be careful with this as there is no research out there to support this. The Slimmer can be purchased at many stores including Walgreens and Bed Bath and Beyond.
The effortful swallow uses an actual swallow with the added resistance by producing force with the swallow. You have to have the patient not only “swallow hard” but an important component of the effortful swallow is to forcefully push the tongue against the palate, therefore creating pressure for the swallow. (Bulow, M., Olsson, R. & Ekberg, O. (1999). Videomanometric analysis of suprglottic swallow, effortful swallow, and chin tuck in healthy volunteers. Dysphagia, 14, 67-72.) (Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language, and Hearing Research, 51, S276-300.) (Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Parts I-V. JRRD, 46, 175-222.)
There are also exercises that I use that are “swallowing-based” such as changing the consistency, texture, weight of the bolus, one of my favorite exercises (you’d know this if you read my previous blog posts) is having the patient suck pudding through a straw and then change to a smaller straw as the patient progress. This not only has the person swallow but strengthens the oral phase of the swallow through sucking, which is a natural motion of swallowing (we all use a straw at some point). Mastication exercises are good, if the patient is not appropriate for an actual bolus, I use a mesh baby feeder or cheese cloth. Any exercise you can have the patient complete that adds resistance or complication to their natural swallow is what we need. Remember, evidence-based can also be what YOU trial, track and possibly research.
Now, there are times that I do use NSOME’s, I know, right, gasp. I find that STRETCHING the articulators/swallowing mechanism is quite good for patients that have been through radiation therapy, for example. If they are unable to move the articulators to the maximum benefit, yes, I will combine oral stretches/massage/myofascial release to the mix (above exercises) for maximum benefit.
Will tongue exercises, jaw exercises, etc work outside of the context of swallowing/speech, I really don’t think they will. You have to train the muscles to do what they’re supposed to do for function. To do that, you HAVE to combine exercise/therapy with the intended movement. You cannot rehabilitate speech without using speech and you cannot rehabilitate swallowing without having your patient swallow, even if it is only their own secretions. Make certain that what you are doing is working for your patient, if the tongue exercises don’t seem to be changing anything, by the data you track, change what you are doing! We are therapists adn are trained to use a variety of techniques. If you are uncertain about where to go next, ask. Don’t be afraid to ask questions.
When having your patients exercise, whether it be the speech or swallowing system, look to your physical therapist for ideas. They exercise their patients, however they relate the exercise to the actual act (i.e. walking) and combine the exercises with the act of walking. They don’t have their patients do leg exercises and send them home expecting them to walk with more efficiency. They also exercise their patients with walking and make it more difficult (without the walker).
Remember when using Swallowing Oral Motor Exercises, use plenty of repetition, add resistance and make it worth your and your patient’s time!